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HomeMy WebLinkAbout1425A (15) WORKERS•�oMPENSAT�oNOE��ARAT,oN ; qpp�ICATION FOR PERMIT � � I hereby aff'rm thold C�avi'�v.certifita�e of consenf fo sel( insure,or a cerrfm�e of workers'Compensation i�:��a��e, ,�,364c HEAiING - VENTILATING - AIR CONDITIONING or a cer�if'i'e'�d/�co/�py thereof(Sec 3800 Lob.C.) -�_818(REV.10/81) � O�olicy No.J Y Vo7�Compan . . � .... . . . . . . • 7' Certi{ied cLr�is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAPETY � Cenif' d copy is ftled wiih tha county building tnspec- FOR APPLICANT TO FILL IN BUILDING ��� � (\ Ilon ep Iment. . (PRINT OR TYPE ONLYJ ADDRESS ; r�f Dale � Applicpnl l�l l t,�TT 7�M V N0.� TYPE OF APttIANCE OR EQUIPMENT � FEE `�`ITM "—"�� ER FICATE OF EXEMPTION FROM WORKERY . NEnREST COMPENSAiION INSURANCE . CRO55 ST. . [Th(�sstllon nesd nof be compla}sd ti 1hs work Involwd by ABSORPTION UNIT,BTU D6iRICt NO. FRp�fSSED BY iha parmtt ts for one h�ndrad dollars(SI00)or lea�.) . I terti(y ihat in 1he performonce of ihe work for�whith this AIR HANDLING UNIT,CFM r�{ �� V permit is issued,I shall not employ ony person in any manner gO�LER,BTU so as fo become s�bjecl to Ihe Workers'Compensation lows. nvvaOvatS ont¢ ws CTOR'S SIGNAiURE Dale � APPlicanl COMPRESSOR,BTU ROUGH NOTICE TO APPIICANT: If, after moking this�Certificote of � VENTILATION SYSTEM � � FiNnl Exemptlon, you shovld become subject to tha Workers' . � Compensotion provisions of Ihe lobor Code,you musl iorfh- EVAaORATIVE COOLER � VAUDATI�N wilh comply wlih s�th provisions or this permil shall be � deemedrevaked. � FURNA[E FAU_GRAVITY� LICENSED CONTRACTORS DECLARATION . FLOOR BTU � I hereby a(firm lhat I am licensed under provisions of Chopfer 9 NEATER: SUSPENDED UNIT_ �(commenting with Seclion 7000J of Division 3 of�he 8usiness WA« and Professions Co e,and my license ts In full force and effect:- . , - � 'c'1 4 2 5 A } a License Num er � Lia Class . - - ► #f• • • • •8 V A /� �J 4' Controtlor �N�w Date �1 �J� - - � • • � (1 5� 0 ❑ I am exempl under Sec. • d • � �Jr O� W Plan check fee a. B.BP.C.for this reason� ' . tO � O��9�8 7 L �� PERMI7 ISSUING FEE S Dale: Sgdarure TOTAL FEE ,(� S 0 � � OWNER-BUILDER�ECLARATION� �.�� PInN CHECK acMICAM / ��� / � I here6y affirm�hat I am exempf from the Connac�or's ticense L � � Law for the following reason�Section 7031.5, Business and NAME �tJ.�.�N7� . Professions Code): � � � � - . ❑ I, CS owner of the properfy, or my employees with ADDRE55 j3S ����'�JD wages as Iheir sole compensation,�wiil do ihe work and ��n, TEL.NO. the slrudure is not in�ended or ofFered for sale(SeUion � � � � 7044,Business and Professions Code). OWNFR '��i^ � �, ❑ I,as owner of ihe property,am exclustvely contracting L wi�h licensed con�radors to construct the projeU(Seo- ��� � � tian 7044,8usiness and Professions Code). ADDRE55 CONSTRUCTION IENDING AGENCY arv � � - � �- iei.rv06��Q$cj I hereby affirm tha��here is a consh�ttion lending agency for � , the performance of ihe work for which ihis permil is issued GONTRACTOR ` • - -�- (Set.3097.Civ.C.). �� � . . ._.. . . . .. . . . . � ADDRE55 �1� .. . ___ ._ . � � Lender's Name -' I . - � � � - � -- � � . . CITY L� TEL NO. _ �, - lender's Address ' � � � - � - I cert�f ihat I have read�h�s o I�carion and srate ihot the SiniE . iiC. � - Y pP LICENSE NO. - QA55 � .. above informalion is corred.I ag�ee�o comply with all Coonty � � � �� - -- �� "� - �� � - ordinontes and Stote lows releting to building construdion, � �, . hereby aurho ize representmives of this Coumy to enter� � �. � - � - �� � ��- - - � --- por the abo�e-n�nnoned pro rty lor inspecr�on por'p'o7ses. SEE REVERSE FOR EXPLANATORY LANGUAGE 9 _ 1 ^U/ - S�gna�urn of Ap li nt or Agent Doie . .. . . .... . ._..... -. . . . . . - .-. _ .. . y� '� , ��\ , � - � ' 1� .^I I,1 ` .'� , � '_�r � � ' 1 � � . ' � � -' �� ' ,�; " � � . "' � _" ,, ,• ..1 . , , ` . �� • '.. .. , , �. ' , . . i_ , . • . � m ., 1 .s,.., ..''• � ...,.•, ., � ` '�1� � • ` '. '' - •, . . � � � . ' � � .. • Z - . N _- ' '. . ' _ M .. ^ . 1,. _ - ." \ � � . • . ' . . . _. .' . 1� . � � , 1, � , ' 1 1 � t! , r' \ . . .- . t `I�. �� � ` ' � . � . N . 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